NIOSH AOB DISCLOSURE FORM

1 Do you work, or have you ever worked, at or for a DOE or AWE facility? YES NO

If “yes,” please provide details below (length/type of employment, location(s), etc.), and proceed to Question 

2. If “no,” proceed to Question 3:

Facility Employment Details

*Please attach additional sheets as necessary – Check here for additional sheets: 

2 If you answered Question 1 in the affirmative:

Did your length of employment total 250 days or more? YES NO

During the course of your employment, did any discrete incidents likely to have involved exceptionally high 

levels of radiation exposure occur? YES NO

If you answered “yes” to either of the questions above, please provide additional details:

Facility Details

*Please attach additional sheets as necessary – Check here for additional sheets: 

3 Imputed Interests Under 18 U.S.C. § 208:

Are you aware of any particular matter in which NIOSH/DCAS is involved, in which any of the following 

persons or entities would have a financial interest?

Your spouse YES NO

Your minor child YES NO

Your general partner YES NO

An organization in which you serve YES NO

Any person or organization with whom you are negotiating for prospective employment or have an 

arrangement concerning prospective employment YES NO

If you answered “yes” to any of the questions above, please provide additional details:

Person/Entity Details

*Please attach additional sheets as necessary – Check here for additional sheets: 
4 Covered Relationships Under 5 C.F.R. § 2635.502:

Are you aware of any particular matter involving specific parties, in which NIOSH/DCAS is involved, that is

likely to have a direct and predictable effect on the financial interest of a member of your household?

YES NO

Are you aware of any particular matter involving specific parties in which NIOSH/DCAS is involved, where a 

person with whom you have a covered relationship is or represents a party to such matter? This includes:

Anyone with whom you have or are seeking a business or financial relationship (other than a routine

consumer transaction):

YES NO

A member of your household (including roommates, domestic partners, etc.):

YES NO

A relative with whom you have a close personal relationship:

YES NO

Anyone with whom your spouse, parent, or dependent child is serving or seeking to serve as an officer, 

director, trustee, general partner, agent, attorney, consultant, contractor, or employee:

YES NO

Any person with whom you have served as an officer, director, trustee, general partner, agent,

attorney, consultant, contactor, or employee within the past year:

YES NO

Any organization in which you are an active participant:

YES NO

If you answered “yes” to any of the questions above, please provide additional details:

Person/Entity Details

*Please attach additional sheets as necessary – Check here for additional sheets: 

5 Do you fall within any of the “appearance of bias” categories below (as set forth in the NIOSH AOB 

Policy):

Status as a covered employee under EEOICPA based on employment at the DOE or AWE facility:

YES NO

Employment for any duration in the design, development, or management of radiation safety or

dosimetry records management operations of the DOE or AWE facility: 

YES NO

Covered employment at the DOE or AWE facility for any duration with possible exposure to an acute

radiation exposure incident potentially covered under the definition of a “discrete incident” under 42

C.F.R. § 83.3(c)(i): 

YES NO

Where a spouse, parent, or non-dependent child has the status of either a claimant under the Act or a

covered employee under EEOICPA based on employment at the DOE or AWE facility: 

YES NO

Participation as one of the following: (1) an authorized representative for a claim under EEOICPA; (2)

an SEC petitioner; or (3) an advocate for a claimant or an SEC petition at a specific DOE or AWE facility: 

YES NO
Membership in a union which serves as a petitioner for an SEC petition: 

YES NO

Participation as an expert witness in litigation involving safety or health conditions at the DOE or AWE

facility, when such participation is not deemed a financial conflict of interest under 18 U.S.C. § 208 or

an appearance of conflict under 5 C.F.R. § 2635.502: 

YES NO

Authorship of a report or the delivery of a public statement (including testimony) indicating that you

have taken a position on a particular matter involving specific parties at a DOE or AWE facility,

independent of your position with NIOSH, the Board, or a contractor providing technical support to

NIOSH or the Board, when such particular matter is now at issue in the program: 

YES NO

If the answer to any of these questions is “yes,” please identify the categories that apply and provide 

additional details:

Category Details

*Please attach additional sheets as necessary – Check here for additional sheets: